Evaluation
of urological patients
Dr. Samir Ali
Ass. Prof . Urology
Flank pain/Loin pain/
renal pain
Dull pain
Colicky pain
GI symptoms
Location
◦
Costovertebral angle
◦
loin to groin.
DDx:
Passage of a stone
Clot or tumor colic
UPJ obstruction.
Infection
Other less common causes: renal cystic
disease .
Radiation:
Non urological causes
Musculoskeletal.
Vascular: aortic aneurysm
Medical: Pneumonia/pleurisy, MI
Gynecological and obstetric : Ectopic pregnancy
Gastrointestinal: Acute appendicitis
Neurological/spinal /
Vertebral : spinal nerve root
irritation.
Pain may be referred from the testicles
-
Distinguishing urological from non
urological flank pain
History and examination are most important.
Palpate the abdomen for signs of peritonitis .
Examine the patient’s back, chest, and testicles,
Costo-vertebral angle tenderness.
Urinalysis is critical as it suggests or excludes a
urinary tract cause.
Vesical Pain:
Vesical pain:
overdistension or inflammation
Should be related to the act of micturition
Prostatic Pain:
Prostatic pain is usually secondary to
inflammation with secondary edema and
distention of the prostatic capsule.
Referred mainly to the perineum.
Scrotal /testicular pain
primary:
arises from the testis, or epididymis
Referred pain
Ureteric colic
Inguinal hernia
Nerve root irritation/entrapment
(ilioinguinal/genitofemoral).
acute VS. chronic:
acute pain is usually of inflammatory or
vascular origin as epididymo-orchitis, or torsion, while
chronic pain is usually related to non-inflammatory
conditions such as a hydrocele or a varicocele, and it is
generally characterized as a dull, heavy sensation that does
not radiate.
Hematuria
Is defined as 3-5 or more RBCs/hpf on a
centrifuged specimen confirmed on 2 of 3
properly collected specimens.
Macroscopic (gross) Vs. Microscopic or
dipstick
Causes
Surgical (urological)
Cancer.
Renal or urothelial,
PPP
Stones (urolithiasis).
Infection.
Inflammation.
Trauma (blunt and penetrating).
Renal cystic disease: e.g., medullary sponge kidney.
Congenital abnormalities: vesicoureteric reflux.
Prostatic: benign prostatic hyperplasia (BPH).
Medical (nephrological)
Systemic
hematuria
Urological investigation of
◦
urine culture
(if symptoms suggest urinary infection),
◦
urine cytology
.
◦
upper tract imaging
Diagnostic cystoscopy?
◦
If radiological investigation demonstrates a lesion suggesting a
urothelial carcinoma.
◦
Asymptomatic Microscopic Hematuria recommends cystoscopy in all
high risk patients.
What is the best upper tract imaging study for the
evaluation of hematuria?
US
can detect masses, stones, or obstruction.
IVP
is the traditional modality for urinary tract imaging.
CT
is considered as the
GOLD STANDARD
modality for the
evaluation of urinary stones, renal masses, and renal
infections.
Magnetic resonance imaging (MRI)
is limited in the initial
evaluation of hematuria.
Retrograde pyelography (RPG)
it is now considered of
historical value in the era of CT and MRI
Lower urinary tract symptoms (LUTS)
The classic prostatic symptoms of :
hesitancy, poor flow, frequency, urgency, nocturia,
and terminal dribbling
have in the past been
termed
prostatism
or simply BPH symptoms.
The new terminology
(LUTS)
is useful because it
reminds the urologist to consider possible
alternative causes of symptoms, which may have
absolutely nothing to do with prostatic
obstruction.
Lower Urinary Tract Symptoms
A. Irritative Symptoms
Frequency: Urinary frequency is due either to
increased urinary output (polyuria) or to decreased
bladder capacity (anatomical of functional)
Nocturia : is nocturnal frequency .
Dysuria :is painful urination.
Urgency: difficulty to inhibit desire to urinate
B-Obstructive Symptoms
Decreased force of urination .
Urinary hesitancy
.
Intermittency.
Postvoid dribbling .
Straining.
What’s this test? What's the most important
finding to be excluded by this test?
Incontinence.
Urinary incontinence ; is the involuntary loss of urine.
Types:
◦
Continuous Incontinence .
◦
Stress Incontinence.
◦
Urgency Incontinence.
◦
Overflow Urinary Incontinence.
◦
Mixed urinary incontinence (MUI).
Complete Urine Analysis
Urine analysis is a simple, non-invasive and cheap
laboratory test that rapidly provides valuable
information about the urinary tract and other body
systems.
Complete urine analysis should be performed, even if
one component part shows no abnormalities.
Concurrent serum or plasma biochemical analysis is
often required to gain maximum benefit from urine
analysis.
Method of collection
Should be obtained before a genital or rectal
exam
Urine obtained from a condom, catheter, or
intestinal conduit drainage bag is
NOT
valid
In men:
clean the external meatus, discard the
first 20mls, and collect the next
(MID-STREAM CLEAN CATCH)
In women:
clean the vulva and urethral meatus, separate labia, and
take the (MID-STREAM CLEAN CATCH)
If satisfactory sample cannot be obtained
,
DO NOT
hesitate to use
a catheter
In children:
use plastic bags
(not suitable for
bacteriology), in females
donot hesitate to use a
catheter
.
suprapubic
aspiration is
needed for culture.
Timing
A
freshly voided
specimen a few hours after a meal or
genital examination that is
examined within one hour
is
the best.
Ideally the first morning sample is the best
Casts are particularly vulnerable to disintegration and
will only be detected if fresh urine is examined very
soon after collection.
Parts of analysis
−
Macroscopic (physical)
−
Chemical (Dipstick)
−
Microscopic
−
Culture
−
Cytological
Physical examination
Volume: (0.5 -2.0 L/day)
◦
Increased volume (Polyuria) > 2.0 L/day: -
Physiological: Excessive water and fluid intake.
Pathological:
Diabetes mellitus.
Diabetes insipidus
Chronic renal failure
Diuretics
◦
Decreased volume (Oliguria) < 0.4 L/day:
Dehydration
Acute renal failure (prerenal, renal, postrenal)
APPEARANCE
Normal fresh urine is clear.
Cloudy (turbid) urine is due to abnormal
constituents (
pus cells, bacteria, salt or
epithelial cells
).
Colored:
−
Colorless
Diluted urine
−
Deep Yellow
Concentrated Urine
−
Yellow-Green
Bilirubin / Biliverdin
−
Red
Bld / Hg/beets/rifamp/urisept
−
Brownish-red
Acidified Blood (Actute GN)
−
Brownish-black
metHb,Melanin,alkptnuria
−
Smoky urine
acute GN
−
Orange urine
concentrated/carotinoids
Color:
Normally urine is
clear
, and it’s color is
pale yellow
.
Odor:
Ammonia-like: Urea-splitting bacteria
Foul, offensive:
Old, pus or inflammation
Sweet:
Glucose
Fruity:
Ketones
Specific gravity
Specific gravity
Depends on the concentration of
various solutes in the urine. It’s a
good
indicator of renal concentrating
ability.
Range 1.003 to 1.030
Chemical Analysis
Glucose
Glucose
Bilirubin
Bilirubin
Ketones
Ketones
Specific Gravity
Specific Gravity
Blood
Blood
pH
pH
Protein
Protein
Urobilinogen
Urobilinogen
Nitrite
Nitrite
Leukocyte Esterase
Leukocyte Esterase
Urinary pH
reflects ability of kidney to maintain normal
hydrogen ion concentration in plasma & ECF
Normal range 5-8 (average 6)
Protein
Normal urinary proteins
Protein
% of Total
Daily Maximum
Albumin
40%
60 mg
Tamm-Horsfall
40%
60 mg
Igs
12%
18 mg
Secretory IgA
3%
4.5 mg
Other
5%
7.5 mg
TOTAL
100%
150 mg
Glucose in urine
Normally
no
glucose in urine
Methods:
Benedict’s test (detects all reducing subs)
dip-strips (glucose specific)
Causes of glucosuria
with hyperglycaemia: diabetes, acromegaly, Cushing's
disease, hyperthyroidism, drugs like corticosteroids.
without hyperglycaemia: renal tubular dysfunction
Hemoglobin:
dip-sticks are +ve in
Hematuria
Hemoglobinuria
myoglobinuria
So once positive document the presence of
RBC’s by microscopy
Other tests:
Ketone bodies
Billirubin
Bacteria and leukocytes
Abnormal microscopic findings
Per High Power Field (HPF) (400x)
◦
> 3 erythrocytes
◦
> 5 leukocytes
◦
> 10 bacteria
Per Low Power Field (LPF) (200x)
◦
> 3 hyaline casts or > 1 granular cast
◦
> 10 squamous cells (indicative of contamination)
◦
Any other cast (RBCs, WBCs)
Presence of:
◦
Fungal hyphae or yeast, parasite, viral inclusions
◦
Pathological crystals (cystine, leucine, tyrosine)
◦
Large number of uric acid or calcium oxalate crystals
Crystals
calcium oxalate (mono-and di-hydrate)
calcium phosphate
urate ( amorphus, biurate, uric acid)
cystine
struvite
drug related (sulphonamides…)
All are normal constituents of urine except
struvite
and
cystine
Other tests on urine
Urine cytology
Urine culture and sensitivity
Hormonal studies
Urothelial cancer tests
Studies for stone constituents
Urinary tract imaging
Conventional radiographs
Intravenous urography
Ultrasound
CT scan
Nuclear scintigraphy
Other contrast studies
Cystography
Urethrography
Regrograde pyelography
Plain
radiographs
Landmarks for
kidney , ureter,
and bladder
Parts of ureter
EXU
The Intravenous Urogram is the classic routine
investigation of Uroradiology
Technically satisfactory IVU demonstrates clearly and
completely both the renal parenchyma & the collecting
system including the calyces, renal pelvis, ureters and
the urinary bladder and gives an indication of their
function
It gives information on both the anatomy and function
of the urinary organs.
Indications
suspected renal pathology (stone, mass…)
hematuria
complex UTI
renal colic
trauma
Contra-indications
absolute
relative
Preparation
explain for the patient
Take consent
hydration status (
may need overhydration
)
bowel prep.
laxative
bladder emptying
metformin
Complications
allergic
nephrotoxicity
access related compl.
cardiotoxicity
Contrast material
HOCM
LOCM
Views
prefilm (KUB)
nephrogram
ureterogram
full bladder
post voiding
added views
Renal ultrasound
Basic principles
Frequency/resolution/depth of
penetration
Doppler ultrasound :Scrotum
CT scan
The new standard imaging
Native vs. contrast
Density measured by HU
Stones
,
masses
,
trauma
CT
Isotope scanning
Organic molecule of interest is bound to
radioactive isotope that emits gamma rays
99m
Tc is usually used because of its short
half life of approximately 6 hours
A time-activity curve is recorded and
compared to normal curves.
Can measure the
split renal function
and
document the presence and degree of
obstruction.
Main types
Tc-MAG3
cleared by tubular secretion, no glomerular
filteration, well suited for renal function, diuretic
renogram, and plasma flow
Tc-DTPA
cleared by glomerular filteration, used for renal
function evaluation, less useful in RF
Tc-DMSA
binds to proximal tubule and retained there, thus
images the renal parenchyma looking for scaring.
Other tests
Cystography
Urethrography
VCUG
Loopography
nephrostography
Retrograde pyelography